Arteriovenous fistulae (AVF) are the hemodialysis access modality of choice for patients with endstage renal disease. However, they have a high early failure rate. Good vascular access is essential to manage longterm hemodialytic treatment, but some anesthesia techniques directly affect venous diameter as well as intra- and post-operative blood flow. The main purpose of this meta-analysis was to compare the results of regional and local anesthesia (RA and LA) for arteriovenous fistula creation in end-stage renal disease.
Gao et al BMC Anesthesiology (2020) 20:219 https://doi.org/10.1186/s12871-020-01136-1 RESEARCH ARTICLE Open Access Comparison of regional and local anesthesia for arteriovenous fistula creation in end-stage renal disease: a systematic review and meta-analysis Chen Gao1, Chunyan Weng2, Chenghai He3* , Jingli Xu2 and Liqiang Yu1 Abstract Background: Arteriovenous fistulae (AVF) are the hemodialysis access modality of choice for patients with endstage renal disease However, they have a high early failure rate Good vascular access is essential to manage longterm hemodialytic treatment, but some anesthesia techniques directly affect venous diameter as well as intra- and post-operative blood flow The main purpose of this meta-analysis was to compare the results of regional and local anesthesia (RA and LA) for arteriovenous fistula creation in end-stage renal disease Methods: We conducted a systematic review and meta-analysis to synthesize evidence from randomized controlled trials (565 patients) and observational study (408 patients) with the aim of evaluating the safety and efficacy of RA versus LA in surgical construction of AVF Results: Pooled data showed that RA was associated with higher primary patency rates than LA (odds ratio [OR], 1.88; 95% confidence interval [CI]: 1.24–2.84; P = 0.003; I2 = 31%) Additionally, brachial artery diameter was significantly increased in the RA versus LA group (mean difference [MD], 0.83; 95% CI: 0.75–0.92; P < 0.001; I2 = 97%) and the need for intra- as well as post-operative pain killers was significantly less (RA, P = 0.0363; LA, P = 0.0318) Moreover, operation duration was significantly reduced using RA versus LA (MD, − 29.63; 95% CI: − 32.78 - -26.48; P < 0.001; I2 = 100%) Conclusions: This meta-analysis suggests that RA is preferable to LA in patients with end-stage renal disease in guaranteeing AVF patency and increasing brachial artery diameter Keywords: Arteriovenous fistula, End-stage renal disease, Local anesthesia, Regional anesthesia, Meta-analysis, Systematic review Background The construction of arteriovenous fistulae (AVF) is an established form of therapy for patients with chronic renal failure However, the primary failure rate for AVF creation under local anesthesia (LA) for hemodialysis is * Correspondence: hikiddhechenghai@163.com Department of Internal Medicine, The Affiliated Hospital of Hangzhou Normal University, 126 Wenzhou Road, Zhejiang, Hangzhou, China Full list of author information is available at the end of the article very high; approximately one third of AVF fail at an early stage [1] General anesthesia (GA), regional anesthesia (RA), and local anesthetic infiltration are three acceptable anesthetic techniques used for the surgical construction of AVF; however, the choice of anesthetic technique may significantly affect early patency or long-term AVF outcomes General anesthesia is associated with increased cardiorespiratory complications in patients with end-stage © The Author(s) 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data Gao et al BMC Anesthesiology (2020) 20:219 renal disease Thus, in such patients, RA, such as a brachial plexus block (BPB), or LA are favored for AVF creation However, whilst both local anesthetic infiltration and RA avoid the risks associated with GA, only RA may be used to produce an associated sympathetic nerve block, which increases venous diameter and arterial flow intraoperatively, as well as in the early postoperative period Compared with LA, BPB is thought to improve local hemodynamic parameters However, the effects of both techniques on fistula patency and failure rates are highly controversial Therefore, we conducted a systematic review and meta-analysis to collect evidence from published randomized controlled trials (RCTs) and observational studies to assess the safety and efficacy of LA and RA in the surgical creation of AVF Methods Page of (mm), change in brachial artery blood flow rate (mL/ min), and post-surgery comorbidities) Data analyses and quality assessment We used Review Manager software (RevMan version 5.3) to analyze the extracted data Odds ratios (ORs) were calculated with 95% confidence intervals (CIs) Heterogeneity between ORs for the same outcomes across different studies were explored using the I2 inconsistency test, which describes the percentage of total variation across studies due to heterogeneity as opposed to chance A value of 0% indicates no observed statistical heterogeneity, whilst larger values signify more substantial heterogeneity The studies were assessed using the Cochrane risk of bias tool (Fig 2) and the Newcastle-Ottawa Scale (Table 1) Disagreements between the two independent investigators were resolved via discussion Electronic searches This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations We searched the literature using PubMed, EMBASE, and Cochrane library databases, and included studies published from August 1951 to September 2017 The Medical Subject Headings (MESH) search query used were as follows: arteriovenous fistula OR (arteriovenous AND fistula) AND (anesthesia OR local anesthesia OR brachial plexus anesthesia OR regional anesthesia OR anesthesia OR regional anesthesia OR brachial plexus block OR brachial plexus anesthesia OR brachial plexus blockade OR local anesthesia OR conduction anesthesia OR infiltration anesthesia) We also reviewed the reference lists of eligible studies and reviews to identify any additional relevant studies Disagreement over relevance was resolved by consensus Study selection Study titles and abstracts were screened for eligibility by two independent reviewers Eligible studies included open-label and double-blinded RCTs, as well as retrospective studies with adult open-label participants (≥ 18 years), that compared the efficacy of RA versus LA for AVF creation in end-stage renal disease Studies meeting any of the following criteria were excluded: (a) animalbased studies; (b) studies not published in English; (c) abstracts, editorials, case reports, reviews, and case series The following data and outcomes were extracted and included in the study: (a) study characteristics (including: study design, sample size, follow-up duration, and publication year); (b) primary clinical outcomes (including: primary fistula patency rate, primary fistula failure rate, surgery duration, change in brachial artery diameter Results Details of the auto-selection process are outlined in Fig Overall, studies, including RCTs [2–8] and retrospective study, [9] with a total of 955 patients, met the inclusion criteria The characteristics of all included studies are provided in Table Details of the quality assessments are provided in Fig and Table Clinical outcomes In total, studies, including 852 patients, [2, 3, 5–9] evaluated primary patency rates in RA versus LA; RA was associated with higher primary patency rates than LA (OR, 1.88; 95% CI: 1.24–2.84; P = 0.003; I2 = 31%; Fig 3) The combined data from trials, [6–8] including 284 patients, demonstrated that RA was associated with significantly increased brachial artery diameters compared to LA (mean difference (MD), 0.83; 95% CI: 0.75– 0.92; P < 0.001; I2 = 97%) The combined data from trials, [6, 8] including 144 patients, revealed that LA was associated with significantly reduced branchial artery blood flow compared to RA (MD, 47.5; 95% CI: 35.18– 59.12; P < 0.001; I2 = 83%) Two trials, [4, 6] including 229 patients, reported data regarding operative times, demonstrating significantly longer operative times in RA versus LA (MD, − 29.63 min, 95% CI: − 32.78 - -26.48; P < 0.001; I2 = 100%) Details of the clinical outcomes are provided in Table Complications The combined data from trials, [3, 6, 9] including 594 patients, demonstrated no difference between RA and LA in terms of vascular access infection (MD, 0.68; 95% CI: 0.23–2.02; P = 0.49; I2 = 0%) Three trials, [2, 3, 6] including 163 patients, revealed no significant difference between RA and LA with respect to the incidence of Gao et al BMC Anesthesiology (2020) 20:219 Page of Table Risk of bias assessment Study Selection Comparability Exposure Solomonson, et al 1994 ** ** *** fistula thrombosis (OR, 0.21; 95% CI: 0.03–1.27; P = 0.09; I2 = 0%) Observations after BPBs in trial, [3] including 60 patients, found no significant differences in the blocks until six-weeks post fistula creation (OR, 0.19; 95% CI: 0.01–4.06; P = 0.29; I2 = 0%) One trial, [4] including 103 patients, found a significant difference in pain intensity experienced between RA and LA (P = 0.0363 versus P = 0.0318, respectively), and time to postoperative pain initiation was significantly longer following RA versus LA Operative duration was significantly shorter (P = 0.0007) for RA (67.5 ± 8.9 min) than LA (134.7 ± 14.8 min) Discussion This meta-analysis included 955 patients from studies (7 RCTs and retrospective study) Combined data demonstrates that RA is associated with higher AVF primary patency rates and improved local blood flow compared with LA Moreover, operation duration and the use of pain killers was significantly reduced with RA versus LA Fig Study selection flow diagram Total score Axillary-approached BPB (RA) was preferable to LA Arterial and venous dilation are crucial for AVF maturation [2] yet vascular surgery, such as local infiltration anesthesia, can easily lead to vessel spasm, impairing blood flow and potentially resulting in early fistula thrombosis Comparatively, BPB can be performed using interscalene, supraclavicular, infraclavicular, and axillar approaches [4] In a recent study, BPB was found to provide higher blood flow to the radial artery and AVF compared to infiltration anesthesia [3] given the sympatholytic effect, producing significant vasodilatation, decreased vascular resistance, [10] and increased local blood flow This is consistent with other recent studies showing improvements in arterial blood flow and vasodilatation with RA In a recent study by Nofal et al, [7] the overall mean AVF blood flow was 42.21 ml/min more in the BPB versus LA group Similarly, a report by Malovrh [11] revealed a mean preoperative flow rate of 54.5 ml/min in BPB vessels with a successful outcome versus 24.1 ml/min in vessels that failed LA In another Gao et al BMC Anesthesiology (2020) 20:219 Page of Table Summary of included studies and baseline characteristics of their populations Study Design and study arms Sample Age Sex (n) size (n) (M ± SD, years) Mouquet, et al 1989 RCT (BPB vs LA or GA) 18 Solomonson, et al 1994 Comorbidities (n) Duration of follow up Outcomes Examined 52 ± 16 Male (23); – Female (13) h; days; Brachial artery blood flow 10 days Retrospective 408 study (BPB vs LA or GA) 63 ± 14 Male (245); Female (163) – Fistula failure; Graft infection, neuropathy in the extremity receiving the fistula; Seizure; Cardiac arrest; MI; Death within days Lo Monte, et al 2011 RCT (BPB vs LA) 40 BPB, 66.15 ± 7.55; LA, 66 ± 7.49 Male (23); Diabetes (15); High blood Female (17) pressure (13); Systemic lupus erythematosus (5); Glomerulonephritis (4); Autoimmune vasculitis (3); 100 days PI ratio; Venous / arterial diameter; Vein diameter Sahin, et al 2011 RCT (BPB vs LA) 60 BPB, 43.4 ± 10.7; LA, 46.8 ± 12.5 Male (34); Diabetes (24); Hypertension Female (26) (27); Coronary artery Disease (21) h; days; Radial artery flow; Fistula flow; weeks Thrill presence Shoshiashvili, et al 2014 RCT (BPB vs LA) 103 BPB, 60.1 ± 14; LA, 59.7 ± 13 Male (68); Arterial hypertension (87); Female (35) Diabetes (18); Ischemic heart disease (9); Gastric ulcer (1); Hepatitis B (2); Hepatitis C (7); Osteoblastoma (1) 100 days Meena, et al 2015 RCT (BPB vs LA) 60 BPB, 41.33 ± 12.906; LA, 47.7 ± 12.272 Male (46); Diabetes (8); Hypertension (21); 30 48 Vessel diameter; Peak systolic Female (14) Hypertension (14); IgA (15) h; weeks; velocity; Mean diastolic velocity; Blood flow weeks Aitken, et al 2016 RCT (BPB vs LA) 126 60.8 ± 14.8 months Male (79); Diabetes (34); Ischemic heart Female (47) disease (48); Cerebrovascular accident (9); Hypertension (93) Obesity (41) Brachial artery blood flow; Radiocephalic fistulae; Cephalic vein (wrist) diameter (mm); Brachiocephalic fistulae; Brachial artery diameter (mm); Cephalic vein (elbow) diameter (mm) Nofal, et al 2017 RCT (BPB vs LA) 140 BPB, 39.52 ± 5.46; LA, 42.42 ± 5.41 Male (79); – Female (61) Radial artery internal diameter; Cephalic vein internal diameter Infection (16); Neuropathy (9); Seizure (1); Cardiac event (17) h; week; months Intra-operative pain; Need for intraoperative pain killers; Need for postoperative pain killers; Duration of anesthesia (h); Attitude to the type of anesthesia; Pain intensity, night sleep; Limb immobility; Operation duration (min) BPB brachial plexus block, IgA immunoglobulin A, GA general anesthesia, LA local anesthesia, MI myocardial infarction, PI pulsatility Index Ratio, RCT randomized controlled trial, M ± SD mean ± standard deviatio study by Sahin et al, [3] improved blood flow in the radial artery was significantly greater post- versus preanesthesia Moreover, post-anesthesia and immediately pre-surgery, radial artery blood flow was 56 ± 8.6 mL/ in the BPB group versus 40.7 ± 6.1 mL/min in the LA group (P < 0.001) Finally, Ebert et al [12] reported that both mean arterial and venous blood flow were increased (1.9 and 8.6 times, respectively) after BPB Thus, we conclude that BPB anesthesia techniques in AVF construction can contribute to vessel dilation and reduced vasospasm via sympathectomy-like effects, increasing fistula blood flow, reducing fistula maturation time, and improving the success rates of vascular access procedures Arteriovenous fistulae operations can be performed under GA, LA, or RA General anesthesia is associated with increased morbidity, [13] such as through cardiorespiratory complications in patients with endstage renal disease, whilst LA is associated with complications such as vasospasm and pain and discomfort during surgery [10, 12, 14] By comparison, RA (e.g BPB), which is a targeted injection of LA to specifically block the motor and sensory nerves that supply the operative site, is less complicated than GA and safer than LA [15] Moreover, BPB can be performed under ultrasound guidance, allowing for more accurate placement of the injection needle as well as more rapid onset and longer duration of the block, reduced vascular and neurological complications, and minimization of the volume of LA required [16, 17] Pain control is also an important indicator of surgical success Adequate pain control is extremely important in patients with end-stage renal disease with severe comorbidities [15] The prospective, randomized, clinical Gao et al BMC Anesthesiology (2020) 20:219 Page of Fig Risk of bias assessment study from Shoshiashvili et al [4] showed significantly different results between BPB and LA groups in terms of pain intensity The need for intra- as well as postoperative pain killers was significantly less in the BPB versus LA group (P = 0.0363 and P = 0.0318, respectively) Moreover, time to postoperative pain initiation was significantly higher in the RA versus LA group Thus, we conclude that RA provides better pain control intra- as well as post-operatively in dialysis AVF operations, enabling patients to feel more comfortable [5] Fig Patency of brachial plexus block (regional anesthesia) versus local anesthesia Gao et al BMC Anesthesiology (2020) 20:219 Page of Table Main clinical results Outcome variable Number of convective therapy study arms Number of patients Absolute mean net change [95% CI] I2 Duration of surgery 229 −29.63 [− 32.78, -26.48] 100% Brachial artery diameter 284 0.83 [0.75, 0.92] 97% Brachial artery blood flow rate 144 47.15 [35.18, 59.12] 83% Complication of infection 594 0.68 [0.23, 2.02] 0% Thrombosis 163 0.21 [0.03, 1.27] 0% Hematoma 60 0.19 [0.01, 4.06] – Intraoperative analgesia 103 0.65 [0.30, 1.42] – CI confidence interval, I2 inconsistency test The results of our study are consistent with those of previous meta-analyses In a systematic review of randomized trials (462 patients) and retrospective study (408 patients), Ismail et al [18] reported that RA improves the primary patency rate of AVF compared to LA In conclusion, our meta-analysis suggests that RA is preferable to LA in patients with end-stage renal disease in guaranteeing AVF patency and increasing brachial artery diameter Abbreviations AVF: Arteriovenous fistulae; RA: Regional anesthesia; LA: Local anesthesia; GA: General anesthesia; BPB: Brachial plexus block; RCTs: Randomized controlled trials Acknowledgements Not applicable Authors’ contributions HCH and CG was involved in the study design, participated in drafting the manuscript and also helped to analyse the study data CYW, QLY, JLX were participated in study design and drafting the manuscript All authors have read and approved the manuscript Limitations Our study has several limitations First, BPB can be performed with interscalene, supraclavicular, infraclavicular and axillar approaches We included studies using different approaches for BPB, and did not consider the effects of these approaches in our comparison of LA versus RA Future studies are thus required to explore the effect of different anesthetic approaches on the outcomes of BPB Second, three of the studies included in this study were single-center trials with an inherent risk of bias Moreover, there are relatively few primary studies available in the literature Both factors restrict the generalizability of our findings Third, only short-term data are reported in the literature; thus, future studies are required to explore longer-term outcomes Finally, only one study explored patients’ attitudes towards anesthesia and, thus, future trials are recommended to explore the differences between LA and RA in terms of patient-oriented outcomes Funding Not applicable Conclusions In summary, our meta-analysis suggests that RA is advantageous over LA, providing sufficient branchial artery blood flow to guarantee AVF patency whilst increasing brachial artery diameter to avoid thrombosis and several other related complications Nevertheless, large, head-tohead RCTs with longer follow-up periods are required to support the use of BPB and illustrate the safety differences between RA and LA References Riella MC, Roy-Chaudhury P Vascular access in haemodialysis: strengthening the Achilles’ heel Nat Rev Nephro 2013;9:348–57 Lo Monte AI, et al Comparison between local and regional anesthesia in arteriovenous fistula creation J Vasc Access 2011;12:331–5 https://doi.org/ 10.5301/JVA.2011.8560 Sahin L, et al Ultrasound-guided infraclavicular brachial plexus block enhances postoperative blood flow in arteriovenous fistulas J Vasc Surg 2011;54(3):749–53 Shoshiashvili V, et al Evaluation of efficacy of regional and local anesthesia techniques in arteriovenous fistula criation for dialysis Georg Med News 2014;(236):7–12 Availability of data and materials The datasets used in the analysis was collected by online search, and the datasets analyzed in the current study are available from the corresponding author on reasonable request Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare that they have no competing interest Author details Department of Nephrology, The Hangzhou Fuyang Hospital of Traditional Chinese Medicine, Zhejiang, Hangzhou, China 2The First Clinical Medical of Zhejiang Chinese Medicine University, Zhejiang, Hangzhou, China Department of Internal Medicine, The Affiliated Hospital of Hangzhou Normal University, 126 Wenzhou Road, Zhejiang, Hangzhou, China Received: February 2020 Accepted: 24 August 2020 Gao et al BMC Anesthesiology 10 11 12 13 14 15 16 17 18 (2020) 20:219 Meena S, et al Ultrasound-guided supraclavicular brachial plexus anaesthesia improves arteriovenous fistula flow characteristics in end-stage renal disease patients South Afr J Anaesth Anal 2015;21(5):12–5 Aitken E, et al Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial Lancet 2016; 388(10049):1067–74 Nofal WH, et al Ultrasound-guided axillary brachial plexus block versus local infiltration anesthesia for arteriovenous fistula creation at the forearm for hemodialysis in patients with chronic renal failure Saudi J Anaesth 2017; 11(1):77–82 Mouquet C, et al Anesthesia for creation of a forearm fistula in patients with endstage renal failure Anesthesiology 1989;70(6):909–14 Solomonson MD, Johnson ME, Ilstrup D Risk factors in patients having surgery to create an arteriovenous fistula Anesth Analg 1994;79(4):694–700 Malinzak EB, Gan TJ Regional anesthesia for vascular access surgery Anesth Analg 2009;109:976–80 Malovrh M The role of sonography in the planning of arteriovenous fistulas for hemodialysis Semin Dial 2003;16:299–303 Ebert B, Braunschweig R, Reill P Quantification of variations in arm perfusion after plexus anesthesia with color Doppler sonography Anaesthesist 1995;44:859–62 Brimble KS, Rabbat CG, Schiff D, Ingram AJ The clinical utility of Doppler ultrasound prior to arteriovenous fistula creation Semin Dial 2001;14:314–7 Abrahams MS, Aziz MF, Fu RF, Horn JL Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta analysis of randomized controlled trials Br J Anaesth 2009;102:408–17 Rang S, et al Anaesthesia for chronic renal disease and renal transplantation EAU-EBU Update Ser 2006;4:246–56 Capdevila X, Biboulet P, Morau D, et al How and why to use ultrasound for regional blockade Acta Anaesthesiol Belg 2008;59:147–54 Marhofer P, Schrögendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N Ultrasound guidance improves sensory block and onset time of three-inone blocks Anesth Analg 1997;85:854–7 Ismail A Abdelrahman Ibrahim Abushouk.: regional versus local anesthesia for arteriovenous fistula creation in end-stage renal disease: a systematic review and meta-analysis J Vasc Access 2017;18(3):177–84 Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Page of ... that RA is preferable to LA in patients with end-stage renal disease in guaranteeing AVF patency and increasing brachial artery diameter Abbreviations AVF: Arteriovenous fistulae; RA: Regional. .. brachial plexus anesthesia OR regional anesthesia OR anesthesia OR regional anesthesia OR brachial plexus block OR brachial plexus anesthesia OR brachial plexus blockade OR local anesthesia OR... the safety and efficacy of LA and RA in the surgical creation of AVF Methods Page of (mm), change in brachial artery blood flow rate (mL/ min), and post-surgery comorbidities) Data analyses and